Hindawi Publishing Corporation International Journal of Pediatrics Volume 2010, Article ID 496719, 5 pages doi:10.1155/2010/496719
Clinical Study COVERS Neonatal Pain Scale: Development and Validation Ivan L. Hand,1 Lawrence Noble,2 Donna Geiss,3 Laura Wozniak,4 and Charles Hall5 1 Division
of Neonatology, Department of Pediatrics, Queens Hospital Center, Mount Sinai School of Medicine, 82-68 164th Street, Jamaica, NY 11432, USA 2 Division of Neonatology, Elmhurst Medical Center, Mount Sinai School of Medicine, Elmhurst, NY 11373, USA 3 Department of Nursing, Jacobi Medical Center, Bronx, NY 10461, USA 4 David Geffen School of Medicine, UCLA Medical Center, Los Angeles, CA 90502, USA 5 Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY 10467, USA Correspondence should be addressed to Ivan L. Hand,
[email protected] Received 30 June 2010; Accepted 5 August 2010 Academic Editor: Tai Fai Fok Copyright © 2010 Ivan L. Hand et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Newborns and infants are often exposed to painful procedures during hospitalization. Several different scales have been validated to assess pain in specific populations of pediatric patients, but no single scale can easily and accurately assess pain in all newborns and infants regardless of gestational age and disease state. A new pain scale was developed, the COVERS scale, which incorporates 6 physiological and behavioral measures for scoring. Newborns admitted to the Neonatal Intensive Care Unit or Well Baby Nursery were evaluated for pain/discomfort during two procedures, a heel prick and a diaper change. Pain was assessed using indicators from three previously established scales (CRIES, the Premature Infant Pain Profile, and the Neonatal Infant Pain Scale), as well as the COVERS Scale, depending upon gestational age. Premature infant testing resulted in similar pain assessments using the COVERS and PIPP scales with an r = 0.84. For the full-term infants, the COVERS scale and NIPS scale resulted in similar pain assessments with an r = 0.95. The COVERS scale is a valid pain scale that can be used in the clinical setting to assess pain in newborns and infants and is universally applicable to all neonates, regardless of their age or physiological state.
1. Background The definition of pain was established by the International Association for the Study of Pain (IASP) in 1979 as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” [1]. Newborns and infants are often exposed to numerous procedures during hospitalization which can be characterized as painful. In terms of requirements for pain perception, by 20 weeks gestation, the fetal neocortex is present, and pain pathways to the brain stem and thalamus are completely myelinated by 30 weeks [2]. Pain in neonates is often underrecognized and undertreated [3]. In addition, early exposure to pain has been shown to affect the way babies respond to pain later in life [4]. It is, therefore, important for clinicians to assess and manage pain on a regular basis in order to avoid excessive exposure.
Several validated and reliable pain scales exist to measure acute pain in term and preterm neonates. These scales incorporate a combination of behavioral indicators of pain (e.g., facial expression, body movements, and crying) and/or physiological indicators of pain (e.g., changes in heart rate, respiratory rate, blood pressure, oxygen saturation [SaO2 ], vagal tone, palmar sweating, and plasma cortisol or catecholamine levels) to assess pain in neonates. CRIES is a postoperative pain measurement score that includes crying, the requirement for oxygen supplementation (for SaO2 > 95%), increases in heart rate and blood pressure, facial expression, and sleeplessness [5]. The Premature Infant Pain Profile (PIPP) is a seven-indicator composite measure that includes gestational age, behavioral state, heart rate, oxygen saturation, and facial actions (brow bulge, eye squeeze, and nasolabial furrow) [6, 7]. The Neonatal Infant Pain Scale (NIPS) is based solely on behavioral indicators of pain (facial expression, cry, breathing patterns, movements of arms and
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legs, and state of arousal) [8]. The Neonatal Facial Coding System (NFCS) is a unidimensional measure that includes multiple indicators of facial expression and was developed for use in pain research [9, 10]. Despite the number of pain measures that are available, no single scale can easily and accurately assess pain in all newborns and infants, especially in very low birth weight neonates or those who require mechanical ventilation. The objective of this study was to develop and validate a single pain scale (the COVERS scale) as a measure that can be used clinically to assess pain in newborns and infants regardless of their gestational ages and disease states.
as the COVERS scale. The indicators were later separated and analyzed in accordance with their appropriate scales so that the COVERS scale could be compared to the already validated scales.
2. Methods
3. Results
2.1. Study Participants. Study participants were 21 newborn infants admitted to the Neonatal Intensive Care Unit at Jacobi Medical Center. Infants with congenital anomalies, severe neurological abnormalities or who had received pain medications within 12 hours of the evaluation were excluded from this study. The gestational age of infants ranged from 27−40 weeks. Informed parental consent was obtained, and the study was approved by the Institutional Review Board.
Pain scores were measured for 21 newborn infants, 57% male, 0−80 (mean 22.6) days old, with gestational age ranging from 27−40 (mean 34.9) weeks. Of the 21 newborn infants included in the study, 13 were premature (
